Interview Vascular News

Vascular News talks to Jean Pierre Becquemin, Professor of Vascular Surgery at Henri Mondor Hospital Creteil, Paris, France, and one of the founders of the Controversies and Updates in Vascular Surgery meeting, about the challenges facing vascular surgery and his love of mountaineering…

When did you first decide you wanted a career in medicine?

I was about 17 years old, I did not really know what to do as a job after graduation, however I did know what I did not want to do:  to stay behind a desk filling forms. In the end what probably decided my choice was the example given by the general practitioner of our family. He was a smart, handsome  and very dedicated man and I admired him a lot. Taking care of people, trying to relieve the pain, and to fight diseases in the way he did, was something I felt ready for.  I have never regretted that choice.

So what attracted you to vascular surgery?

In the seventies vascular surgery was a relatively new sub speciality and I was not aware of all the aspects of the Day to Day practice. Probably the fact that  in this field of surgery,  surgeons attempted  not to remove organs but to repair them was important.  Also what made and still makes vascular surgery so fascinating is the broad range of knowledge and skills it requires. Pre-operative investigations, medical treatments of various and severe conditions,  decisions for and planning of operations are  the intellectual part of this job. Also the unique atmosphere of the operating theatre where the technical aspects of this splendid surgery could be developed was of paramount importance.  I was anxious to be up to the job which requires at the same time quick and sound judgement, patience and persistency, taste for perfection, and also a cold-blooded temper to face unexpected and sometimes dramatic situations.  Many of these traits of characters are also required in another of my passions : mountaineering . Amazingly, I think that another but unconscious reason for me to choose vascular surgery was the history of Jacques Oudot. He was the physician who in 1952 accompanied the French climbers to Annapurna. This 8000 meters summit located in the Himalayas chain was the first mountain of this altitude to be successfully climbed by human beings.  Like many French ,  in those years, we were,  in my family,  fascinated by the feat of this successful and dramatic ascent.  During my medical study I learnt that Jacques Oudot was also a famous vascular surgeon in France. Among his numerous accomplishments, he was the first to perform a fem-fem bypass.

Who have been you the biggest influences?

Early in my career, it was probably, Charles Dubost, a cardiac surgeon who was the first to successfully repair an abdominal aneurysm. Alain Carpentier impressed me a lot by his charisma along with his inventiveness and remarkable surgical skills. Henri Bismuth tought me that the first quality of a surgeon was to work in rigorous ways. Among vascular surgeons Jean Michel Cormier and Jean Natali were also very influential. Later one when endovascular procedures emerged as a potentially effective and less invasive therapy I was lucky enough to be able to share views with pioneers in that field and among them Juan Parodi, Ted Dietrich and James May.  For the scientific aspects there is no doubt that Michel Huguier  an academic general surgeon played a key role in my interests in medical writing, statistics and by large in the setting of large studies. 

….and your proudest moments in your career?

That is difficult to say. I was very proud to receive the recognition of my peers when I became a Professor of Vascular Surgery. I was also proud of having papers accepted in distinguished journals (especially the New England J of Medicine) and to be part of international meetings.   However, I think a highlight was in 2004 when the British Vascular Society honoured me by making me an honorary member of the Society. As you know the British and the French have a history so I was delighted of having been chosen. It is something that I will always be proud of. Similarly to become Honorary member of the American Society for Vascular Surgery was a kind of international recognition which I did not dare to dream of.  

What gave you the idea behind Controversies and Updates in Vascular Surgery?

We started Controversies and Updates in Vascular Surgery in 1992. At that time we were somewhat fed up with formal conferences by leaders who were so indisputable that there was no or little place discussions. So we launched the idea of contradictory debates starting with areas of uncertainty.   We thought that it was a way to improve the quality of the arguments since speakers knew their talk would not be accepted right away and that contradictory opinions would follow. The truth, if any, would come out of the confrontation of those ideas and the attendees could make up their own minds. It is great fun.

Has the meeting changed?

“Yes, it has changed a lot. We were quite amateur at the beginning it was a small meeting. Each year we have become more professional in organising and now we have achieved a very good level of professionalism. Since we invite renowned speakers from all over the world, the quality of the presentations has improved a lot.  Finally the creation of a web site has been instrumental.
International meetings such this one in Paris, create opportunity to mix academic views with the ideas of practicing surgeons. I think, in France it there was a demand. There are many skilled and well trained surgeons in this country. They may not be as good in research and academic achievements because of the educational system which prevail in French Medical Universities and Hospitals (fortunately changes are currently underway). Apparently, in North Europeans countries, physicians are more dedicated to science and research than we do. Thus these exchanges are very good since we have a lot to learn from each other.”

What do you think are the biggest challenges facing vascular surgery in France?

We have a problem with attracting trainees, each year there are less trainees coming through. Also in medical school 75 % of students are women and few of them are attracted by such a demanding specialty. This is a problem because people in France and throughout Europe are living longer, and more people will require vascular treatments. Thus if there are fewer trainees,  sooner or later there will be a problem.
One solution may come from the EU. In some countries too may physicians are trained  and some of them might be attracted by the French way of living and find a position here. Obviously they are many obstacles. A unified training system is necessary. The UEMS certificate is an excellent first step.  It will take time but it may be that in a few years, surgeons will be permitted to practice vascular surgery indifferently in the different countries belonging to the EU.
In France at the moment we also have the issue of reimbursement for novel stent grafts and also for other innovations like carotid stenting. The huge deficit of the healthcare budget is a key point and the emergence of evidence based medicine in the reimbursement systems although not bad per se, is a problem with innovations.   I think physicians in France will have to work very hard to change the rules for reimbursement. Carotid stenting and stent grafts are reimbursed in selected cases for which in my view the some indications are disputable. 

Do you think these problems are reflected throughout Europe?

I think each country in Europe has dealt with this problem differently and I am not in a position to comment on that. Of note is that for reimbursements, Great Britain found an acceptable solution with the EVAR trials.  The funding for the stent grafts and the assessments of the procedures were performed concomitantly. At the end, evidences are provided on which Health Care Providers can make their decisions. On the other hand, during the duration of the study patients who may benefit from the innovation can be treated. Obviously the difficulty in conducting such large trails, limit the applicability to a broad range of new devices.  We were fortunate enough to obtain a grant from the French Ministry of Health to conduct and independently controlled study comparing F and B grafts and open surgery at a national level. Early clinical results have been published in Annals of Surgery and the current cost effectiveness assessment will appear in a forthcoming  EJVS issue. 

What are you current interests in medicine?

I like to investigate new treatments such as aortic stent grafts and carotid stenting. I was the very first academic surgeon in France to have treated a patient with a bifurcated customized stent graft. It was back in 1994. I was also from the beginning, engaged with other European surgeons who decided in 1995 to evaluate this new technique through a collaborative work. It was the birth of the Eurostar registry, the results of which are still valid 20 years later.  I am still fascinated by the rapid evolution of the technology especially fenestrated and branched stent-graft and the enlargement of endovascular interventions for difficult situations such as aortic dissection.  I like pushing the limits, analysing successes and most importantly failures, drawing conclusions and trying to improve the overall results.  I like the way vascular surgery is changing, 20 years ago we had only open repair, now we have endovascular interventions. Who knows what advances there will be in the future? As a physician, to be involved in this move is very exciting and stimulating.  Teaching vascular surgery to young trainees, to share with them the enthusiasm and passion of offering the best available treatment and most importantly to make them aware of all aspects of the decision-making process play also an great part in my interest in practicing medicine. 

How do you relax outside of surgery?

I play the piano and I am keen on literature reading. I also enjoy photography and of course, mountaineering. I don’t climb steep rocks any more, I gave those up some times ago, but I still enjoy hiking in high and remote mountains. I find it both relaxing and adventurous. But of course, my family takes my spare time. I have four children and the youngest is sixteen, so I don’t get to hike so much. Finally, Yoga helps me to keep a balanced life.